Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 2, 2003, pp. 149-150

Indian Journal of Surgery, Vol. 65, No. 2, March-April, 2003, pp. 149-150

Editorial

Surgery for ulcerative colitis from bags to pouches

Adarsh Chaudhary

Department of Gastrointestinal Surgery, Gobind Ballabh Pant Hospital, Jawaharlal Nehru Marg, New Delhi 110002
Address for correspondence: Dr Adarsh Chaudhary, Department of Gastrointestinal Surgery, Gobind Ballabh Pant Hospital, Jawaharlal Nehru Marg, New Delhi 110002. Email: adarsh@nda.vsnl.net.in

Paper Received: January 2003, Paper Accepted: January 2003. Source of Support: Nil

Code Number: is03024

Ileo-anal pouch anastomosis (IAPA) has replaced proctocolectomy and ileostomy as the standard operative procedure for patients with ulcerative colitis. Proctocolectomy with ileostomy is a safe and simple operation with predictable results, but the necessity of a permanent stoma is its major drawback. Since the description of IAPA in 1978, the procedure has undergone many technical refinements and is being accepted by a large majority of patients. Attention is now focused on the critical evaluation of the functions of the ileal pouch and its impact on the patient's quality of life.

In several large series, nearly 90 per cent of patients report excellent results after IAPA. Most patients pass 4 to 8 stools in a day, are able to defer emptying for at least up to 30 minutes. They are fully continent during the daytime with occasional episodes of nocturnal soiling and can discriminate between flatus and faeces without fear of soiling. Some patients do need to make minor dietary adjustments to regulate the frequency and consistency of stools. Similarly, nearly 20 per cent of patients regularly take antidiarrhoeal medications. On long-term follow-up, no significant malabsorption problems have been detected after IPAA. Patients have also been reported to have increased muscular strength, lean body mass and work capacity after ileo-anal anastomosis.¹ During pregnancy, pouch function usually remains stable, though some transient changes like increased frequency may occur during the third trimester.² Vaginal delivery can be safely conducted in patients with an ileal pouch, though in patients who have a fibrosed pelvis due to pelvic sepsis or those with a scarred perineum, a caesarean section may be indicated. Proper selection of patients and good surgical technique contribute markedly to a good outcome. Whether elderly patients have poorer pouch function is debatable and it would be unreasonable to deny any patient the benefit of IAPA just because of age.

Issues that are debated in the surgical performance of IAPA are whether mucosectomy is necessary or avoidable, and the choice of anastomoses whether hand-sewn or stapled, and lastly if a routine single-stage IAPA without ileostomy is safe. As is true with many controversies, here too definite answers are not available. Perioperative morbidity leading to mortality has been reported in 1 per cent of patients undergoing IAPA with a 30-day complication rate of 20-30 per cent.³ Previously undiagnosed Crohn's disease and pouch-specific complications like pouch related fistulae, pelvic sepsis and pouchitis may be responsible for pouch failure. Pouch dysfunction resulting from surgical technique may be because of retained rectal mucosa, a long efferent limb of the pouch and anastomotic strictures. Fortunately, pouch dysfunction is not synonymous with the need to excise the ileal pouch and revert to a permanent ileostomy. Salvage of the pouch is a distinct possibility with acceptable functional results.⁴

The common postoperative complications after IAPA are intestinal obstruction, pelvic sepsis and pouchitis. Intestinal obstruction after pouch anal anastomosis usually resolves with conservative management as the obstruction in the majority is caused by adhesions. Pelvic sepsis adversely affects pouch function and therefore must be prevented. Pouchitis remains the commonest complication after IAPA with a 10-year cumulative incidence between 24-46 per cent.⁵ Patients with pouchitis present with increased frequency, urgency, abdominal cramps and bleeding. Since these symptoms are non-specific, endoscopy and biopsy are essential for a reliable diagnosis of pouchitis. Pouch disease severity index is a useful objective tool to grade the severity of pouchitis and should be used more often in clinical practice.⁶ The exact etiology of pouchitis remains elusive. Fortunately, majority of patients with pouchitis respond to antibiotics.

National data about ulcerative colitis are sadly lacking. A wider interaction, between gastroenterologists and surgeons interested in this field, is necessary to study the incidence and pattern of ulcerative colitis in India and the prevalent therapeutic practices. The newly formed National Forum for Inflammatory Bowel Diseases is expected to fulfill this gap in the disbursal of information. This will be of immense help in standardizing the treatment strategies for our patients.

REFERENCES

1. Jensen MB, Houborg KB, Vestergaard P, Kissmeyer-Nielsen P, Mosekilde L, Laurberg S.Improved physical performance and increased lean tissue and fat mass in patients with ulcerative colitis four to six years after ileoanal anastomosis with a J-pouch. Dis Colon Rectum 2002;45:1601-7.
2. Ravid A, Richard CS, Spencer LM, O'Connor BI, Kennedy ED, MacRae HM,et al. Pregnancy, delivery and pouch function after ileal pouch-anal anastomosis for ulcerative colitis. Dis Colon Rectum 2002;45:1283-8.
3. Fazio VW, Ziv Y, Church JM, Oakley JR, Lavery IC, Milsom JW, et al. Ileal pouch-anal anastomoses: complications and function in 1005 patients. Ann Surg 1995;222:120-7.
4. Dayton MT. Redo ileal pouch_anal anastomosis for malfunctioning pouches-acceptable alternative to permanent ileostomy? Am J Surg 2000;180:561-4.
5. Shen B, Achkar JP, Lashner BA, Ormsby AH, Brzezinski A, Petras RE, et al. Endoscopic and histologic evaluation together with symptom assessment are required to diagnose pouchitis. Gastroenterology 2001:121:261-7.
6. Sanborn WJ, Tremaine WJ, Batts KP, Pemberton JH, Phillips SF. Pouchitis after ileal pouch_anal anastomosis: a pouchitis disease activity index. Mayo Clin Proc 1994;69:409-15.

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